The invisible injuries of service members resulting from our nation’s war on terrorism pose complex challenges for military families, especially military children. With injuries such as post traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI), there are often dramatic changes in personality and behavior without a change in one’s appearance. This “injury duality” — looking the same, but not acting the same — is troubling for family members, friends and co-workers, and can be particularly confusing for children who thrive on parental consistency, trust and safety.

This Courage to Care addresses the vulnerabilities of children whose service member parent suffers an invisible injury. This injury may include not only PTSD and mTBI, but also depression and health risk behaviors (i.e. increased use of alcohol and illegal or prescription medications, etc.) that are prevalent in many returning service men and women. Health professionals who work with military families and children should be alert to the effects of these kinds of injuries on children and on parenting, as this essential component of healthy development is often disrupted due to the family’s injury experience.

Secondary Traumatization

Many children may develop symptoms that mirror those of their injured parent. An example might be a young child having nightmares because of their parent’s nightmares or because they are worrying about their parent’s behavior. A child may have trouble paying attention at school or exhibit new behavioral problems because he or she is thinking about her parent’s problems. This impact on a child due to their worry and identification with their injured parent is sometimes referred to as “secondary traumatization.” A child’s symptoms can get worse if there is not a parent who can acknowledge the effects of the parental injury and communicate with their children to help them feel better.

Impact of Invisible Injuries on Children

The unique nature of PTSD, mTBI or disorders such as depression – causing changes in personality and/or behavior without altering physical appearance — is especially confusing for children of all ages. The following signs and symptoms exhibited by children may indicate distress and require professional assistance.

Increased acting out behaviors, such as disobedience, tantrums, or risk-taking behaviors

Emotional distress, such as crying, increased anxiety, or withdrawal

Feelings of loss and grief related to the change in the injured parent

Feelings of isolation

Feelings of embarrassment about the injured parents’ appearance or behavior

Misinterpreting parent mTBI-related fatigue and apathy as indicators that the parent no longer loves them

Feelings of anger or resentment about new responsibilities or changes in the family such as having to care for younger children, even sharing in or taking on the care of the injured parent

Feelings of self-blame for the injured parents’ irritability

Helping Children Integrate the Parental Injury Experience within the Family

Healthcare and family support professionals should encourage families to:

Seek out resources and instrumental support. Families may require that basic needs be met in the areas of finance, medical care, military concerns, housing, education, and child care. Children may need special services and/or supports to address any behavioral/mental health problems that develop or to connect them with community resources that provide them with social support and structured activities.

Support and help monitor their children’s stress. As children deal with stress, they may find it difficult to express emotions, to relax, or to calm themselves. Parents can teach children to label and express their emotions giving them specific strategies (i.e., deep/belly breathing, progressive muscle relaxation, or visualizing a safe space).

Share information with children about the injury in a way they can comprehend it. Particularly important is information that helps children understand what the injury is, what the effects of the injury are in terms of parent functioning and/or symptoms, and what to expect over time. Children may need reassurance that the injury is not their fault and that specific symptoms/emotional changes in the parent are expected. This helps to normalize and contextualize the family’s current difficulties and helps children understand what is happening in their family.

Develop problem solving skills and goal setting. Particularly important is helping children identify relevant problems, name their goals, brainstorm possible solutions, and pick a solution to try out. Goal setting helps families identify how they would like things to be different, and how to monitor change. Parents and children can select family goals together and practice them as they plan for future challenges, recognizing incremental improvements over time.

Posted on BrainLine May 13, 2011. Reviewed July 26, 2018.

From the Uniformed Services University of the Health Sciences, www.usuhs.mil, and the Center for the Study of Traumatic Stress, Bethesda, Maryland, www.cstsonline.org. Used with permission.

This program is made possible in part by a grant from the Bob Woodruff Foundation, which is dedicated to ensuring that impacted post-9/11 veterans, service members, and their families are thriving long after they return home.

BrainLine is a national service of WETA-TV, the flagship PBS station in Washington, D.C.